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WEBINAR REPLAY WITH DR. TUMAINI RUCKER COKER
Listen to “Equity in ADHD Care”
Serious disparities in health care for African American and Latinx children with ADHD are well documented. As rates for ADHD diagnosis increase across the population, a growing body of literature highlights barriers to ADHD diagnosis and treatment – from the clinical level to systemic factors – that disproportionately impact children and adolescents of color. These inequities have created and deepened societal divides that put Black and Latinx children at greater risk of poor educational outcomes.
Sufficiently addressing disparities in care starts with an understanding of why racial and ethnic imbalances matter, the roots of these inequities, and their consequences for overall health and well-being. Pediatric clinicians can further work to reduce ADHD stigma and improve equity in ADHD care by providing culturally relevant care, and by applying treatments to meet the specific needs of children in African American and Latinx families.
Health Equity: Why It Matters for ADHD Care
Early childhood experiences and environmental influences can have a profound impact on developmental trajectories and eventual health outcomes. We can observe this through the school-to-prison pipeline, where Black students can suffer severe consequences for behaviors associated with and triggered by their symptoms.
The School-to-Prison Pipeline
This model describes how schools’ harsh disciplinary reactions to behavioral concerns, including zero-tolerance policies, can push children out of the educational system and into the juvenile justice system. Talking back to a teacher, as an example, can be interpreted as a form of intimidation, possibly leading to suspension, expulsion, or even arrest for a behavior that should result in a trip to the principal’s office at worst.
Ample data shows that Black students are more likely than are white students to be placed in this school-to-prison pipeline. In fact, they are suspended and expelled three times more often than are white students.1 And when students are suspended or expelled for behavior, they’re almost three times more likely to be in contact with the juvenile justice system in the following year.2
Black children are also disciplined at higher rates for certain behaviors than are white students. According to an analysis of a Seattle school district over one year3:
- 52 percent of students suspended for disruptive behavior were Black, compared to 24 percent who were white
- For interference with school authority, 56 percent of students suspended were Black, versus 6 percent who were white
- For disobedience, 44 percent of students suspended were Black students, compared to 25 percent who were white
Certain populations are even more at risk. Black boys are three times more likely to be suspended than are white boys; Black girls are six times more likely to be suspended from school than are white girls.4
Research also shows a disproportionate use of suspensions and expulsions for children with disabilities, even at the preschool level. According to the Center for American Progress 5, preschool students with behavioral problems represent about 4 percent of all preschoolers, but make up 70 percent of children who have had a suspension or expulsion. The same report found that preschoolers with ADHD, who comprise just 2 percent of the preschool student population, made up 53 percent of preschool suspensions and expulsion. Harsh discipline for behavioral concerns at this early age is particularly problematic, since children at the highest risk for this type of discipline – Black children, Latinx children, low-income students, and children with disabilities – are also more likely to experience multiple adverse childhood experiences, which may manifest as the behaviors for which they are routinely punished.
[Childhood Trauma and ADHD: A Complete Overview & Clinical Guidance]
ADHD, African American Youth, and Incarceration
Studies have found significant rates of ADHD among incarcerated populations. One meta-analysis estimates that 25 percent of the incarcerated population has ADHD, with the prevalence increasing to 30 percent among incarcerated juveniles.6
Given what we know about the school-to-prison pipeline, could it be that ADHD, which can affect school behavior, increases the odds of incarceration for African American youth and adults?
The authors of 2014 publication7 hypothesized that ADHD symptoms would be commonly interpreted as school behavioral problems in African American children, which would then be associated with negative teacher ratings and lower standardized test scores. This, in turn, would predict more suspensions, expulsions, and juvenile arrests, which would then predict arrest in adulthood. In the end, the study’s findings were largely consistent with the hypothesis.
Harsh discipline approaches, of course, lead to other adverse consequences. Nearly half of high school students with three or more suspensions will drop out of school.8 Today, African American children, despite comprising 16 percent of the youth population, represent 44 percent of youth in juvenile facilities. And as of 2015, Black youth are more than five times as likely to be detained or incarcerated compared to white youth.9
Health Equity: Improving ADHD Care
Behavioral Parent Training
Given the severe consequences for school behavior problems at school, particularly among Black children, one way to improve equity in ADHD care is through behavioral parent training (BPT) – specifically to meet the needs of African American families.
Why focus on BPT? Studies have shown that combination treatment of ADHD with BPT and ADHD medication, is most important for children in low socio-economic households, particularly for those who are African American or Latinx.10
Despite parent training being an important component of a child’s treatment program, it is not a service that is readily accessible in many clinical settings, or widely provided in primary care. But even with access, another important challenge is providing BPT in a way that maximizes parent engagement.
Parenting Styles
Understanding diverse parenting styles is a prerequisite to discussing parent training among Black families. Parenting styles have been described in three broad categories, which have been found to differ among families by race and ethnicity:
- Authoritarian parenting, where parents have high behavioral expectations and often utilize more punitive disciplinary strategies
- Permissive parenting, where parents have few demands or behavioral expectations, limits, or restrictions
- Authoritative parenting, defined as a balance between the appropriate behavioral expectations and responsiveness to the child. Much of parent training for ADHD focuses on strategies that emphasize this parenting style (like praising compliant behaviors and ignoring negative ones), which is thought to be the most effective form of parenting in terms of positive child behavioral outcomes.
Researchers have found, on average, that African American parents are more likely than white parents to use an authoritarian parenting style. Historical and sociopolitical contexts can help explain the functional significance of this type of parenting. By understanding these contexts, clinicians can adjust and adapt the content of behavioral training to meet the needs of Black families.
Parenting in African American Families
This historical context of African American parenting starts in slavery, through Jim Crow, and the civil rights movement, through present day. And through all of this history, to our current societal realities, African American parents are faced with the challenges of preparing their black children to endure racism and unfair treatment.
Historically, children made up a substantial portion of enslaved Africans in the U.S. Of the 12.5 million Africans trafficked to the U.S. before 1865, nearly a quarter were children. These children were subjugated to all of the horrors of slavery, including brutal violence, separation from family, sexual assault, and trauma. Parents who were slaves had no authority over their own children, and, in many cases, had to watch them suffer abuse from slavers and overseers, or see them sold away.11 12
When slavery ended, the injustices facing young Black children persisted. Thus, African American parents continued to teach their children how to show complete reverence and compliance to white people in public, as any deviation from the white definition of “appropriate behavior” from a Black child could lead to severe consequences.11 12 One of the most notorious examples of this is the case of Emmett Till, who was lynched in Mississippi in 1955 at age 14 after a white woman falsely accused him of whistling at her. She later admitted that she lied, but for the perceived sleight, Till was kidnapped, brutally beaten, and murdered.
This trend continues to the present day with Black youth killed by police officers. Tamir Rice, of Ohio, was 12 years old in 2014, when he was shot and killed for playing with a toy gun in a park; Laquan McDonald was shot and killed at 17 by Chicago police as he walked away from officers in 2014; Kwame Jones was 17 when he was shot by police at a traffic stop in Jacksonville, Florida, in 2020. These are just a few of too many examples.
Adjusting Behavioral Parent Training
Given historical contexts for Black parenting, BPT programs must be adjusted and adapted to better engage these families. This may be achieved with the following strategies, among others:
- Providing scenarios and videos to which parents can connect and relate
- Using providers who have similar lived experiences to encourage and facilitate participation
- Changing wording and delivery of strategies; overcoming language barriers
- Providing courses in local neighborhoods with other parents that have similar lived experiences; using mobile options and online tools
- Understanding racial socialization, or teaching children how to effectively cope with racism
These changes can significantly improve the BPT experience for Black parents. I can personally attest to this, having undergone parent training with my husband for our twin boys with ADHD some years ago. Though I, as a pediatrician, intellectually understood the concepts of BPT, it wasn’t until the instructor in class showed a video of a Black mother using BPT techniques on her daughter that I emotionally understood.
Health Equity: Other Disparities in ADHD Care
Clinicians also need to understand how these additional factors lead to inequity in ADHD care from diagnosis to treatment:
- Diagnosis and medication rates: A number of studies have found that Black and Latinx children, when compared to white children, are less likely to receive a diagnosis of ADHD and to take a medication for ADHD.13 14 Black and Latinx children are also more likely to discontinue medication and disengage from treatment compared to white children. 15
- Racism and discrimination: Black and Latinx children who report perceived racial and ethnic discrimination are more likely to have symptoms of ADHD, mood disorders, and other mental health conditions compared to white children.16
- Trust: Black parents have lower trust in their providers than do white parents.17 They are less likely to have racial concordance, and therefore a shared lived experience, with their provider, which is part of a larger pattern of distrust in the healthcare system due to a legacy of racial discrimination.
Health Equity: Conclusions
Childhood experiences and influences — like racism, poverty, and other stressors — greatly shape developmental trajectories and potential health outcomes in adulthood. Inadequate intervention for ADHD in Black and Latinx children is multifactorial – the result of low levels of trust in medical providers due to historical trauma, coupled with health disparities, including in diagnosis and treatment, and less access to care. Furthermore, inadequate treatment for ADHD behaviors in children of color will and can result in serious consequences at school that have an overall negative impact on their health and wellbeing. This is why it is crucial for clinicians to provide early and adequate intervention for ADHD in these children.
The content for this article was derived with permission from “Equity, Diversity, and ADHD: Achieving Equitable ADHD Care for African American and Latinx Children,” presented by Tumaini Rucker Coker, M.D., MBA, as part of the 2021 APSARD Annual Virtual Meeting.
Health Equity in ADHD Care: Next Steps
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